If you could build an EM system from scratch…

This blue sky question is part of the reason that more than a thousand emergency physicians gathered in San Francisco this week. Every country is at a different stage of EM development, but some have a relatively clean slate to work with. Take Dr. Jim Holliman for instance, the man in charge of EM development in the entire country of Afghanistan. Not only does Dr. Holliman have the chance to help a country start fresh with their EM strategy, he’s here at ICEM hearing lessons-learned from more than 60 country delegates. In theory, someone like Holliman should be able to pick and choose the best elements of every system. Of course, that’s putting it way too simply (particularly considering the physical danger inherent in many regions), but it brings up an interesting question that I’d like to pose to the blogosphere: If you were designing an EM system from the ground up, what are some specific elements from the American system that you would keep and what would you toss out like old garbage? And remember, we’re talking about a clean slate. The sky’s the limit.

First, have a law to kill any civil litiation like a good samaritan clause. As long as you’re trying to do good, you can’t sue. Let the emerg people do as much as they can as fast as they can (my throw out). Keep the integration between EMS and base hospital ala the R Adams Cowley Shock Trauma system in Maryland. I have no idea if it’s still the best, but they were the pioneers.

The most productive “emerg” I was ever a part of was in the field at the Caribana parades in Toronto (published in Prehospital Emergency Care). We could work as fast as needed with really tight integration between EMS, Police and the base hospital. I often think that if you could replicate that model (and I suspect they do in war zones) that you’d have a great system.

1. Tort / liability reform as suggested. The emergency department is not primary care, it’s triage and emergencies. Until that permeates the thick skills of everyone, not much progress can be made. And until non-patients can be refused unnecessary care, and system-abusers refused access, they will continue to clog up the system.

2. That means we need a more robust network of clinics or “urgent care” centers, especially in urban areas. Perhaps attached to the EDs, for convenience. Perhaps integrated with. But there needs to be a system to separate the “wheat from the chaff”.

3. I like the better integration between ED and EMS. I’ll go one better. Pull the EMS away from the Fire Service, and have EMS do “house calls” and “wellness calls” to follow up with the indigent, patients who had been discharged from the ED, etc. Yeah, I know. Their heads will explode. But until EMS is a true “extension of the emergency room” that we have been touting for near 30 years, then it’s not as useful as it could.

4. Put a physician or APN or PA in triage. Let them make decisions right there, write prescriptions, etc. Making it past the first level of triage gets you tracked to a specialty area: a) you need an xray or some other radiographic study, b) you need a “level II” assessment (I just made that up), c) level III assessment (critical care bed in the ED).

5. There needs to be an integrated patient database across the country with basic information, including generic codes for treatments and medications prescribed. To allow physicians to be able to identify abusers of the system.

Adding “just this one more little form…this one more box to check…phrase to add” (for payment or otherwise), makes the chart a bunch of boxes and disjointed phrases that, in the end, reveal very little about what’s actually going on with the patient. Communication between providers is lost. And medical-legally it’s difficult to defend.

Let’s get rid of the excess paper…and get back to documenting what we feel is pertinent. It has gotten so bad that, even in triage, if we’re just doing a wound check 4-5 pieces of paper are required to get the person out the door. 60 second visit = 10-15 minute documentation exercise!! Multiply this by…80 (or whatever your fast track numbers are) and lots of time is *lost*.

…all by adding “just this little box to check”…or phrase to write…or form to fill out.

I would make the EMS similar to Wisconsin’s State Patrol. The State Patrol has districts with a certain amount of “smokies” in each district in proportion to the districts population.
My “new” EMS would be all paramedic; have a career track and be state employees. Payment for their services would come from insurance assessments. Freeloaders or abusers of the system would be fined.
Oh, and a tangent thought; the only way to get into nursing or doctor school would be to start as an EMT. You would have to have at least 2 years in the “emergency medical system” before you could apply to a nursing or doctor school.
Do you know how many 4 year nurses, that I’ve precepted in the ER, had never touched a patient???
Steve